The Josiah Macy Jr. Foundation recently held a series of six regional conferences highlighting innovations in graduate medical education (GME). The Macy Foundation sponsored conferences in 20101 (jointly with the Association of Academic Health Centers) and 20112 that generated recommendations for reform in the governance, financing, and content of GME to make it more accountable and more aligned with the needs of the public. Subsequently, the Institute of Medicine issued a report entitled Graduate Medical Education That Meets the Nation’s Health Needs.3 This report made a strong case for GME reform and made specific proposals to promote that reform. Ensuing discussions have focused on disagreements about the amount and distribution of federal funding for GME. Though the basic case for reform has not been refuted, there has been no consensus about how it should be achieved at the national level.
Through the Macy Foundation’s efforts, we wanted to try to change the discussion to one that is about the innovations needed to better prepare residents for the changing world of practice they will be entering and for meeting the needs of the patient population they will serve. We knew that innovations were taking place at the local and regional levels. We wanted to celebrate these innovations and make it possible for everyone to learn from them. Our hope was that local and regional changes could become national changes by a more grassroots approach.
The conferences were a success on many levels. We had in total more than 800 enthusiastic participants from 39 states and the District of Columbia. The participants were uniformly grateful for the opportunity to present their innovations and to learn from colleagues who are also promoting changes in GME. The conferences validated the importance of their career pathways and gave them new ideas to take back to their institutions.
In reflecting on the success of the conferences and on my recent experiences on an Accreditation Council for Graduate Medical Education (ACGME) task force on the characteristics and responsibilities of GME-sponsoring institutions in the year 2025, I have concluded that there is a real hunger and capacity for change in the GME world. I also have concluded that an organizing theme of that change could be the empowerment of residents.
At a time when many have expressed concern about impending shortages in the number of health professionals; unmet health needs of large segments of our society; and pressure on health care systems to meet fiscal, service, and quality goals, we should be thinking of the resident and fellow workforce—more than 120,000 strong—as a valuable resource to help address these issues. This college-educated, medical-school-educated workforce with one to seven years of postgraduate experience is currently being underused vis-à-vis societal needs. Their prior education and training should be taken advantage of to improve care and access. If these talented young women and men had gone into other professional fields, they would already be in positions of greater responsibility.
But if we are going to reap the full benefit of this talent, we have to change our mind-set about the role of GME in our increasingly complex and distributed health care systems, which will be the primary sponsors of these programs. We can no longer think of the residents merely as “filling slots” in the schedule for coverage. We need to think more creatively about how residents can be deployed to help accomplish the multifaceted mission of the modern and evolving health system they are a part of. Residents can be part of outreach programs to underserved communities; they can be active participants in practice transformation in a variety of ambulatory sites; and they can be an important part of initiatives to improve quality, safety, efficiency, and access in their health systems.
We heard many examples of resident empowerment presented across the six conferences as summarized in our conference report.4 Residents are involved in transforming ambulatory care practices at the Henry Ford Health System in Detroit, at Advocate Lutheran General Hospital near Chicago, and in the “Clinic First” outpatient residencies reviewed by the University of California, San Francisco Center for Excellence in Primary Care. Residents are being deployed into the community to care for vulnerable underserved populations at Florida International University, at Kaiser Permanente of Southern California, and at Zuckerberg San Francisco General Hospital and Trauma Center. This is also exemplified by the role of residents in the newly created, Health Resources and Service Administration–funded Teaching Health Centers, the largest of which is Detroit Wayne County Health Authority (now known as Authority Health). Resident empowerment also can and must occur as part of essential inpatient training. Residents can be effective leaders and participants in quality improvement projects (as at the University of California, San Francisco), patient satisfaction projects (as at the University of Virginia), care transition projects (as at Grady Memorial Hospital), and resource stewardship projects (as at Vanderbilt University). In fact, many institutions are finding that residents may be the best physicians for all of these inpatient projects because they are the closest to the ground and more comfortably work in the interprofessional teams that are necessary for the success of these projects.
These examples are but the tip of the iceberg if you think about what 120,000 talented and motivated physicians-in-training can do if appropriately directed and supported. There are some caveats, however. Empowerment must not mean that residents are totally on their own. Interprofessional faculty must actively guide and support residents if they are to be effective in their newly empowered roles. The degree of empowerment must be developmentally appropriate, as determined by faculty assessment.
Empowered residents also will take more responsibility for their own learning by identifying those areas in which they need help or additional work to be effective in expanded roles. This leads to the idea of “coproducing” learning as a partnership of resident and faculty, analogous to coproducing health as a partnership of professionals and patients.5 Residents who have a greater role to play in achieving institutional goals or in accomplishing social missions are more likely to take more responsibility for their own learning because they can directly see and use the feedback they receive.
This will require rethinking the hierarchical structure of our academic system. Residents and faculty need to work together in a more collegial relationship that fosters independent thought and curiosity. The empowered residents will be both getting and giving feedback, and they must be treated as full team members. This is not dissimilar to the cultural change needed to promote effective interprofessional education and collaboration.6
The empowerment of residents will better prepare them for their future roles as practitioners, community leaders, and teachers. Involvement in community outreach, care for the underserved, quality improvement projects, and stewardship work will give residents the skills they need to be the leaders and change agents of the future. Another dividend of empowerment may be a reduction in burnout. Residents who feel a sense of purpose as part of institutional and societal missions are more likely to feel fulfilled in their work.
To achieve the full benefit of empowerment there will need to be a greater individualization of training, based on residents’ interests and competencies. This may mean allowing residents to differentiate earlier to pursue training pathways consistent with career goals. It also likely means having residents spending longer time in one site or service to develop the familiarity and trust necessary to have maximum impact. Although these changes may create scheduling difficulties for program directors (and I am sympathetic as a former program director), they are highly desirable changes to prepare residents for their different career pathways and to obtain maximum value from residents as contributing members of the health care workforce.
All of this will require a much closer working relationship between the executives making up the “C-Suite” within health systems and those responsible for GME programs. Designated institutional officials and program directors need to be at the table to understand system and institutional priorities, and system executives need to better understand the capabilities of residents and the objectives of the programs. The ideal synergy is for program goals to align with system goals and for the system to be more aware of both the obligations and opportunities in having these talented trainees as part of the system. It also will be important that the ACGME and the Resident Review Committees give adequate flexibility for the residents to be appropriately empowered and for their programs to be optimally individualized. ACGME milestones may need to be adapted to take in to account these expanded roles. The ACGME Clinical Learning Environment Review program7 is an important step in the right direction in recognizing the centrality of the relationship between the institution and GME programs in creating the optimal learning environment that will bring out the best in the residents for the benefit of the system and the public.
I believe resident empowerment should be a driving theme of ongoing GME reform. We can and must derive more value from the extraordinarily talented workforce of residents and fellows. Society will be the beneficiary. But so, too, will be the sponsoring institutions and, importantly, the residents and fellows themselves. Thus, we can truly say in regard to the current state of the health system, “GME is not a problem, it is part of the solution.”
Acknowledgments: The author wishes to acknowledge the hard work and invaluable contributions of the six chairs of the regional conferences and the institutional cosponsors: Donald W. Brady, MD, Vanderbilt University School of Medicine; Diane C. Bodurka, MD, MPH, University of Texas MD Anderson Cancer Center; Robert B. Baron, MD, MS, University of California, San Francisco School of Medicine; Suzanne Allen, MD, MPH, University of Washington–WWAMI Regional Medical Education Program; Debra Weinstein, MD, Partners HealthCare; and Joseph C. Kolars, MD, University of Michigan Medical School.
3. Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. July 29, 2014.Washington, DC: National Academies Press.
5. Batalden M, Batalden P, Margolis P, et al. Coproduction of healthcare service. BMJ Qual Saf. 2016;25:509–517.
6. Thibault GE. Reforming health professions education will require culture change and closer ties between classroom and practice. Health Aff (Millwood). 2013;32:1928–1932.
7. Weiss KB, Bagian JP; CLER Evaluation Committee. Challenges and opportunities in the six focus areas: CLER national report of findings 2016. J Grad Med Educ. 2016;8(2 Suppl 1):25–34.